Bilateral Forearm Approach for Bilateral Forearm Approach for ppppSubclavianSubclavian Artery total occlusion Artery total occlusion

intervention under Filter wire intervention under Filter wire protectionprotectionprotectionprotection

HsiuHsiu--Yu Fang, MDYu Fang, MDChiungChiung--Jen Wu MDJen Wu MDChiungChiung--Jen Wu, MDJen Wu, MD

Division of Cardiology, Division of Cardiology, Kaohsiung Chang GungKaohsiung Chang GungKaohsiung Chang Gung Kaohsiung Chang Gung

Memorial Hospital, TaiwanMemorial Hospital, Taiwan

Clinical HistoryClinical HistoryClinical HistoryClinical History

A 76A 76--yearyear--old femaleold femaleRisk Factor : HypertensionRisk Factor : HypertensionRisk Factor : HypertensionRisk Factor : HypertensionPresented with Presented with –– Frequent dizziness with left arm weaknessFrequent dizziness with left arm weakness–– Right arm soreness (Right arm BP : 106/71 Right arm soreness (Right arm BP : 106/71 g ( gg ( g

mmHg and Left arm BPmmHg and Left arm BP : 165/81mmHg): 165/81mmHg)2D echocardiography:2D echocardiography:2D echocardiography: 2D echocardiography: –– Adequate LV performanceAdequate LV performance–– LVEF= 73 %LVEF= 73 %

EKGEKGEKGEKG

Sinus rhythm

Brain MRIBrain MRIBrain MRIBrain MRI

Carotid duplex showed right common carotid artery 70% stenosisCarotid duplex showed right common carotid artery 70% stenosisCarotid duplex showed right common carotid artery 70% stenosis Carotid duplex showed right common carotid artery 70% stenosis but Brain MRI showed 50% stenosis over right common carotid but Brain MRI showed 50% stenosis over right common carotid artery; Right artery; Right subclaviansubclavian artery total occludedartery total occluded

StrategyStrategyStrategyStrategy

Diagnostic coronary angiographyDiagnostic coronary angiographyDiagnostic carotid angiographyDiagnostic carotid angiographyDiagnostic carotid angiographyDiagnostic carotid angiographyCarotid artery stenting if neededCarotid artery stenting if neededRevascularizeRevascularize and stenting right and stenting right subclaviansubclavian artery via bilateral approachartery via bilateral approachsubc a asubc a a a te y a b ate a app oaca te y a b ate a app oac

Baseline Coronary AngiogramBaseline Coronary AngiogramBaseline Coronary AngiogramBaseline Coronary Angiogram

Vi l ft b hi l t h (l ft di l t t ll)Via left brachial artery approach (left radial artery too small)

Carotid AngiogramCarotid AngiogramCarotid AngiogramCarotid Angiogram

L ft tid t (L t l Vi ) Ri ht tid t (AP Vi )Left carotid artery (Lateral View) Right carotid artery (AP View)

During Carotid AngiographyDuring Carotid AngiographyDuring Carotid AngiographyDuring Carotid Angiography

Right subclavian artery had delayed flow with near total occlusion

Successful puncture Right Brachial Successful puncture Right Brachial ttarteryartery

L ft d Ri ht b hi l t h d i l 70 HLeft and Right brachial artery had maximal 70 mmHg pressure gradient

Right Axillary Artery AngiogramRight Axillary Artery AngiogramRight Axillary Artery AngiogramRight Axillary Artery Angiogram

Multiple collaterals to axillary artery

Retrograde Terumo 0 035 wire passedRetrograde Terumo 0 035 wire passedRetrograde Terumo 0.035 wire passedRetrograde Terumo 0.035 wire passed

ContraContra lateral injectionlateral injectionContraContra--lateral injectionlateral injection

Critical stenosis of right ostium subclavian artery

Filter wire protection to RICAFilter wire protection to RICAFilter wire protection to RICAFilter wire protection to RICA

PTA + Stent to Right Subclavian arteryPTA + Stent to Right Subclavian arteryg yg y

Ultra-Soft 6.0x20mm ; Wanda 10x40mm ; Express LD Stent 10x25mm

Retrieve of Filter WireRetrieve of Filter WireRetrieve of Filter WireRetrieve of Filter Wire

Final AngiogramFinal AngiogramFinal AngiogramFinal Angiogram

Good final TIMI 3 flow to Right Subclavian artery

Final Pressure GradientFinal Pressure GradientFinal Pressure GradientFinal Pressure Gradient

No more pressure gradient between bilateral arm

Take Home MessageTake Home MessageTake Home MessageTake Home Message

SubclavianSubclavian artery total occlusion is one of the artery total occlusion is one of the leading cause of bilateral forearm blood leading cause of bilateral forearm blood pressure discrepancypressure discrepancyBilateral forearm approach is feasible and safety Bilateral forearm approach is feasible and safety yyin in subclaviansubclavian artery interventionartery interventionFilter wire protection in internal carotid arteryFilter wire protection in internal carotid arteryFilter wire protection in internal carotid artery Filter wire protection in internal carotid artery may protect distal embolization while performing may protect distal embolization while performing PTA toPTA to subclaviansubclavian arteryarteryPTA to PTA to subclaviansubclavian arteryarteryUtilized CTO technique like contraUtilized CTO technique like contra--lateral lateral injection may achieve final successinjection may achieve final successinjection may achieve final successinjection may achieve final success